Skip to main content
The Center for International Rehabilitation Research Information and Exchange

Home > Simulations > Simulation 6: Mexican Immigrant

Scenario #6: Mexican Immigrant, Senor Hernan Riojas-Cortez

Learner Group:PT,SLP, (Dentist, Pharmacist andMD by phone, can be learners or confederates)

Environment: Home Care

Authors: Karen Panzarella

Facilitator directions

Main focus

  1. On-site twoHCPs to jointly prioritize patient care issues
  2. Identify contributing factors to current change in patient status; fever, limited mobility, elevated blood sugar, skin breakdown
  3. Identify and understand cultural barriers that could influence patient compliance and plan for care
  4. UseSBAR communication for exchange of all pertinent patient care amongHCPs (physician, dentist, pharmacist)

Performance measures

1 T PT/SLP review previous home care visit notes for baseline information and standing orders
2 T PT/SLP initiate focused assessment to include: interview with wife and patient, vital signs, heart sounds, lung sounds and respiratory effort,O2 sat, and oral cavity screen
3 T PT/SLP initiate secondary assessment to include: pain, skin integrity, last bowel movement, urine output and character, ability to chew and swallow, intake of fluids and food, mobility and identify changes since last evaluation byHCP
4 C PT/SLP reviews medication schedule and compliance status
5 B PT/SLP contact Dentist for history and useSBAR to communicate assessment
6 C Dentist to determine when or if patient needs to be seen in the office or ER
7 B PT/SLP contact Pharmacist for medication reconciliation and useSBAR to communicate assessment
8 B PT/SLP contactMD and useSBAR to communicate current status and possible new orders
9 C PT/SLP to create a plan for medication management
10 B PT/SLP to identify resources and create a plan to ensure patient has follow-up visits
11 T PT/SLP documents patient assessment, status, change, interventions, plan, critical conversations and outcomes

Skills/tasks/procedures

  1. SBAR communication tool
  2. Situational Awareness/Cultural considerations
  3. Prioritization following primary and secondary assessment
  4. Accessing Resources
  5. Decision Making

Imbedded challenges

  1. Wife/caregiver talks for patient and gives conflicting information, speaks primarily Spanish with limited English
  2. Patient speaks primarily Spanish with very limited English
    Patient portraying "machismo" and noncompliant with meds
  3. PT last saw patient last week, was progressing well
  4. SLP has just taken over this patient case from previousSLP
  5. HCPs unaware patient had dental surgery - wife went ahead with scheduled extraction since it took 7 weeks to get the appointment
  6. Multiple current and non-current dose medications in a jumble in a basket on the counter - daily pill count box is "lost" somewhere", patient refuses to take medication

Synopsis of scenario

72 year old Hispanic male who is being visited byPT andSLP at a joint home healthcare visit. Patient was discharged from the hospital (inpatient x 1 week) four weeks ago after a mild stroke (left brain with right sided weakness with swallowing and speech issues).

The patient had oral surgery (unrelated to hospital course) 5 days ago. An apparent infection has ensued and the patient has eaten very little food, drank very little fluids, and has not taken all his medications. He also has had decreased mobility for 2 days (he can ambulate to the bathroom, but prefers to stay in his bed).

Today's date is the 10th of the month.

Learner roles

  1. Dentist- by phone (can be confederate)
  2. SLP
  3. Pharmacist - by phone (can be confederate)
  4. PT
  5. MD- by phone (can be confederate)

Confederate roles and scripting

Role Tone Timing of participation Lines / Comments
Wife/Caregiver

Speaks limited English, Spanish is primary language

Gives conflicting information

Onset of scenario

I just did his blood sugar and hour ago and it was 320.

He can take his little pills but not those big ones you know. It's too hard for him to swallow. He keeps telling me he doesn't want to take the medicine, he is being macho.

Theres just too many pills to keep track of. That's why I keep them all here in this basket.

Complains about husband unwilling to take medication and did not want to call anyone for help other than family members Throughout scenario

I don't want to throw away the old ones cause they are all so expensive and what if he needs them again?

He's been up a lot until the past few days. He's been in bed for 2 days now. Won't even get up to eat. Just lays there and sleeps. Won't even drink a ginger ale.

We went to the oral surgeon because it was scheduled before his stroke. Just about put me under getting him there and back. I am plumb worn out from taking care of him.

Patient information

Hernan Riojas-Cortez

Name: Senor Hernan Riojas-Cortez
Age: 72
Weight: 195 lbs
Height: 5'7"
Gender: Male
Religion: Roman Catholic
Support: Wife

Past medical history

Chronic recurring kidney infections. Diabetes x 3 years controlled with Metformin and diet.

History of present illness

Mild stroke 4 weeks ago with residual right sided weakness, slurred speech, and some difficulty swallowing. Did well withPT at home 2x week for 3 weeks after discharge.PT is now just weekly. Has weeklySLP visits for speech and swallowing. Home health aide comes 2x week to help with bathing and personal care, but wife many of times refuses the help.

Social history

Retired from the railroad. Active in community events and belongs to an Elk's club.

Report to participants

Today's date: 10th day of the month.

SLP: "you are a covering for vacation for the regularSLP that has been working with Senor Cortex for the past 3 weeks in home care. You know that the patient had a (L)CVA and has speech and swallowing difficulties.

PT: "you have been treating this patient twice a week for the past 3 weeks in his home; he has been progressing with ambulation with a quad cane for 80 feet with supervision x 1. You are working on functional mobility and patient/family education."

Technician staging

Staged for learners Available for learners to use

Manikin orSP

Gender: Male

Clothing: Pajamas

Position: Supine

Male

Pajamas

Laying in bed; head up (multiple pillows)

Foul odor coming from mouth

Infected tooth extraction area

Skin turgor indicates dehydration

Patient has slightly slurred speech and speaks primarily Spanish, which is stable from previous history

(R) sided weakness arm, leg

Environment

Patients home in bedroom

Loud TV or radio turned on

Multiple rumpled throw rugs on floor

Multiple TV and electrical cords easily pulled or tripped over

Equipment

Regular bed

Quad Cane at bedside

Commode at bedside and Urinal

Glucometer - results 340

Medications

Will have to create med intake discrepancy in pill bottles to match Pharmacist, Dentist andMD discussions; assuming that today's date is October 10th.

Warfarin 2mg po daily

EC-ASA 81mg po daily

Simvastatin 20mg po nightly

Lisinopril 10mg po daily

Metformin/glyburide 500/5mg 2tabs po twice daily

Amoxil 500mg 1 capsule three times a day for 7 days

Additional other outdated medications in old bottles in a basket: Expired Metformin ER, Lipitor 40mg, Glucosamine/Chondrointin, Chromium,MTV, Warfarin 1mg, Cinnamon, TylenolPM, Pericolace, Tums, Ex-lax.
Labs
Xrays
Other Diagnostics
Chart Records

Home Health Care Notes from last 2 visits

Home Health Care Notes and Orders blank for this visit documention

Dental history

Pharmacy medication records

MD history, physical, and plan of care as of 2 weeks ago

Progression of events

Manikin Actions Performance Measures Cues
Confederates In and Out

0-5 minutes

HR: 96
R: 20-22
BP: 140/86
Temperature: 101
SpO2:

Auscultation sounds

  • RRR
  • Clear bilaterally
  • Active X 4 quads

Manikin Vocals

Mental status:

Tone:

Script: "I have pain in my mouth, it hurts when I swallow"

Other: Speech is slightly slurred from stroke, English is broken, some Spanish words

  • PT/SLP review previous home care visit notes for baseline information and standing orders
  • PT/SLP initiate rapid focused assessment to include: vital signs, heart sounds, lung sounds and respiratory effort,O2 sat, and interview patient and wife
  • PT/SLP initiate secondary assessment to include: pain, skin integrity, last bowel movement, urine output and character, oral cavity, ability to chew and swallow, intake of fluids and food, mobility and identify changes since last evaluation byHCP
  • PT/SLP reviews medication schedule and compliance status
  • PT/SLP contact Dentist for history and useSBAR to communicate assessment

Wife keeps interrupting with conflicting information see script

Wife states that her husband is being macho and doesn't want to take the medicine

5-10 minutes

HR: 96
R: 20-22
BP: 140/8
Temperature: 10

SpO2:

trend over       minutes

Auscultation sounds

  • No change
  • No change
  • No change

Manikin Vocals

Mental Status:

Tone: slightly agitated

Script: "She won't listen to me, She never listens." " I am the Man, I do not want to take pills" "puedo tomar el dolor, no quiero las pastillas" (I can take the pain, I don't want the pills)

Other:

  • Dentist should recognize (given history of oral surgery and current symptoms) that the patient has an infection
    • Review drug allergies and medications with RN
    • Prescribe effective antibiotic avoiding allergic reaction and untoward drug interactions
  • Schedule patient for evaluationASAP. If patient is not transferable, schedule home visit
  • Pharmacist needs to determine how many tablets of the patients medication he should have left in the bottles at home, given the days supply, fill date, and directions for use
  • Pharmacist needs to determine which medications can be crushed and if they can't be crushed a recommendation on a formulation change

10- 20 minutes

HR:
R:
BP:
Temperature:

SpO2:

trend over       minutes

Auscultation sounds

Manikin Vocals

Mental Status:

Tone:

Script:

Other:

Integrated debriefing guide

Threads Performance Measures Debriefing Prompt
Opening

Give us a quick summary of what happened.

What went well?

What didn't go so well?

Understand clinical presentation Dentist to determine when or if patient needs to be seen in the office

What signs and symptoms would you expect for this type of patient?

What signs and symptoms were present?

How did the patient describe his/her symptoms?

What other presentations can produce similar symptoms?

Identify contributing factors

What co-morbidities were present?

What risk factors were present?

Recognize a change in patient status

What was concerning at this point?

Please explain.

What was the call for help based on?

Identify correct intervention / treatment

What is the accepted standard of care for this type of patient?

How was it used?

What other options for care would be reasonable?

What other clinical resources could be accessed?

Understand cultural implications

What cultural influences may be present?

Are there any inherent risk factors for this population?

What does "machismo" have to do with the patient refusing medication? How does antibiotics differ from pain meds in this decision?

Assessment

PT/SLP initiate rapid focused assessment to include: vital signs, heart sounds, lung sounds and respiratory effort,O2 sat, andFSBS

PT/SLP initiate secondary assessment to include: pain, skin integrity, last bowel movement, urine output and character, oral cavity, ability to chew and swallow, intake of fluids and food, mobility, identify changes since last evaluation byHCP

What specific assessments are important to consider with this type of patient?
Infection Control What kinds of infection control practices occurred? What should occur?
Medication Administration PT/SLP reviews medication schedule and compliance status What types of drugs should be considered for this type of patient? How can we make sure the right medication gets to the right patient?
Patient Safety Describe factors that create a "culture of safety". Describe "work arounds" required to care for this patient.
Documentation

PT/SLP review previous home care visit notes for baseline information and standing orders

PT/RN documents patient assessment, status, change, interventions, plan, critical conversations and outcomes

What is important to document?

How can we manage documentation during a critical event?

Communication

PT/SLP contact Dentist for history and useSBAR to communicate assessment

PT/SLP contact Pharmacist for medication reconciliation and useSBAR to communicate assessment

PT/SLP contactMD and useSBAR to communicate current status and possible new orders

What thoughts do we have about this exchange?

What additional information would be helpful?

What are some ways we could improve on sharing information?

How can we advocate for specific action when team members are uncooperative?

What information is most important when transferring patient care?

Situational Awareness Cultural Considerations

How might the concept of Machismo conflict with a rehab program? How might it enhance a rehab program?

Were the big picture or task focused?

What are strategies for keeping the big picture in view?

Decision Making Prioritization

PT/SLP to create a plan for medication management

PT/SLP to identify resources and create a plan to ensure patient has follow-up

What information was necessary to make a decision? What cultural considerations need to be explored?

How were decisions made?

What resources could be accessed?

Leadership

When was there a clear leader?

Did everyone know their role?

How were the roles delegated?

How could the workload be divided up differently?

Professional Behavior To patient, family, otherHCPs

How were we coming across?

What was the team performance like?

What would happen if the "regular" team was not present? What are some strategies for managing difficult interactions?

What was the conflict and how was it managed?

Closing

What would we do differently next time?

Any other questions or comments?